Health Declaration Forms

Sample template: self declaration health form

Questions for Health Declaration Forms

1.

Do you have any allergies?

The answer should be a single choice:
  1. Yes
  2. No
2.

Do you have any medical conditions that require immediate attention?

The answer should be a single choice:
  1. Yes
  2. No
3.

Have you ever had an allergic reaction to a vaccine?

The answer should be a single choice:
  1. Yes
  2. No
4.

Do you have any chronic conditions? If so, please briefly describe below.

The answer should be a single choice:
  1. Yes
  2. No
5.

Are there any changes that should be made for future vaccines or treatments?

The answer should be a single choice:
  1. Yes
  2. No
6.

Have you ever had any adverse reactions to medications or treatments? If so, please briefly describe below.

The answer should be a text input.
7.

Do you have a current prescription for any medication?

The answer should be a single choice:
  1. Yes
  2. No
8.

If yes, please list the name of each medication:

The answer should be a text input.
9.

Are there any changes that should be made for future vaccines or treatments?

The answer should be a single choice:
  1. Yes
  2. No

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